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. 2026 Apr 9;27:427. doi: 10.1186/s12891-026-09789-8

Facilitators and barriers to rehabilitation exercise adherence among patients after total hip and total knee arthroplasty: a qualitative meta-synthesis

Nuo Chen 1, Xue Yuan 1, Yuanyuan Yin 1, Ying Chen 1,✉
PMCID: PMC13181971  PMID: 41957591

Abstract

Objective

This study aimed to systematically search and synthesize qualitative research data regarding the facilitators and barriers affecting rehabilitation exercise adherence in patients following Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA).​

Methods

Relevant qualitative studies were retrieved from both English and Chinese databases, including PubMed, EMBASE, CINAHL, Web of Science, Cochrane Library, CNKI, Wanfang Database, VIP Database, and China Biology Medicine database. The search period spanned from the establishment of each database to September 1, 2025. The PICO framework was adopted to develop the search strategy. Two researchers independently conducted literature screening, data extraction, and quality assessment. The quality of the included studies was evaluated using the qualitative research appraisal criteria proposed by the Joanna Briggs Institute (JBI). Data synthesis was conducted in accordance with the thematic synthesis method proposed by Thomas & Harden (2008).

Results

A total of 19 studies were included, involving 205 TKA patients, 111 THA patients, and 17 healthcare providers. The study results were derived from these 19 qualitative studies and obtained using the thematic synthesis method. From these studies, 78 original findings were extracted, categorized into 10 new categories, and further synthesized into 2 meta-themes:​Facilitators to rehabilitation exercise adherence for THA/TKA patients: Self-motivation and rehabilitation goals, effective rehabilitation strategies, establishment of doctor-patient trust, and multidimensional support networks.​Barriers to rehabilitation exercise adherence for THA/TKA patients: Physical symptoms and functional limitations, fear of movement, cognitive biases, lack of rehabilitation-related knowledge, psychological stress and negative emotions, and socio-environmental constraints.​These two meta-themes reflect the interactive and multi-level characteristics of the factors affecting rehabilitation exercise adherence, revealing the relationship between individual subjective factors, medical and health service factors, and social environmental factors in the process of patients' rehabilitation exercise.

Conclusion

The evidence-based findings of this study derived from thematic synthesis reveal the multi-dimensional factors influencing rehabilitation exercise adherence in patients after THA/TKA. These findings provide a basis for understanding the contradictions and demands in the process of patients' participation in rehabilitation exercises, and can serve as a reference for healthcare professionals to develop targeted intervention strategies. This helps optimize the management of patients' rehabilitation exercises, thereby promoting postoperative joint function recovery and accelerating the rehabilitation process.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-026-09789-8.

Keywords: Total hip arthroplasty, Total knee arthroplasty, Rehabilitation exercise adherence, Qualitative research, Meta-synthesis

Introduction

Osteoarthritis is one of the main causes of joint pain, functional impairment, and even disability in middle-aged and elderly populations. Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) are the primary treatments for end-stage osteoarthritis. By implanting artificial joint prostheses, these surgeries maximize the recovery of patients’ joint function and maintain their physical activity ability [1]. With the advancing aging population, the incidence of osteoarthritis is increasing; when medication and conservative treatments fail, more patients opt for hip or knee arthroplasty surgery. Standardized postoperative rehabilitation exercise is a link in ensuring joint function recovery. It not only enhances muscle strength, improves joint stability, and expands range of motion but also is key for patients to regain functional independence and achieve optimal rehabilitation outcomes. Scientific postoperative rehabilitation exercise can also effectively reduce pain and shorten hospital stay [2]. Conversely, the lack of standardized exercise is likely to lead to decreased joint function and insufficient muscle strength, seriously affecting postoperative quality of life. However, clinically, patients often struggle to maintain regular exercise due to limited physical function and fluctuating psychological status, resulting in poor rehabilitation outcomes. Even 6%-30% of patients experience chronic pain after surgery, which further hinders the rehabilitation process [3]. Therefore, systematically sorting out and identifying the facilitators and barriers to postoperative rehabilitation exercise adherence in THA/TKA patients, and formulating targeted intervention strategies to improve patients’ exercise initiative, are of great clinical significance for optimizing rehabilitation effects and improving long-term prognosis.

At present, scholars have conducted qualitative studies on the rehabilitation experience and exercise-influencing factors of THA/TKA patients, but existing studies have obvious gaps: they have not explicitly categorized the influencing factors of rehabilitation exercise adherence into facilitators and barriers; most studies focus on barriers and challenges in rehabilitation experiences [4] while neglecting the analysis of facilitators; some studies only superficially discuss postoperative rehabilitation experiences, simply summarizing related challenges into a single theme without in-depth subdivision [5]; other studies only list pain and psychological status as barriers, ignoring the restrictive effects of multi-dimensional factors such as social environment [6, 7]. Overall, existing studies mostly focus on single dimensions or specific populations, lacking systematic integration of the facilitators and barriers to rehabilitation exercise adherence. The research conclusions are fragmented, failing to form a comprehensive and systematic understanding. Based on this, this study adopts the thematic synthesis method to integrate existing qualitative research findings, extract the facilitators and barriers to rehabilitation exercise adherence from the perspectives of patients and healthcare providers, provide evidence-based support for clinical interventions, and offer a reference basis for formulating individualized rehabilitation intervention plans and improving the quality of postoperative rehabilitation management.

Method

Research design

We summarized the qualitative evidence on the facilitators and barriers to rehabilitation exercise adherence in patients undergoing THA or TKA through a systematic review and qualitative meta-synthesis. Adhering to the best practice guidelines for synthesizing qualitative research, this study was reported in accordance with the ENTREQ statement [8].​The protocol of this study has been registered in the International PROSPERO, with the registration number: CRD420251142509.

Search strategy

A comprehensive search strategy was adopted to identify potentially relevant qualitative studies on the facilitators and barriers to rehabilitation exercise adherence in patients after THA/TKA. We searched 9 electronic databases from their inception to September 1, 2025, specifically including PubMed, Web of Science, Embase, CINAHL, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, VIP Database, and China Biology Medicine database. This approach ensured comprehensive coverage of studies related to the facilitators and barriers influencing rehabilitation exercise adherence in patients post THA/TKA.​The search was conducted using a combination of subject terms and free-text words. The search keywords included “total hip arthroplasty”, “total knee arthroplasty”, “rehabilitation exercise”, “adherence”, “qualitative research”, “grounded theory”, “phenomenology”, etc. Boolean operators were used to combine the search terms, and manual retrieval was also integrated into the search process.​ The detailed search strategy is provided in Supplementary Material 1.The literature search of this study was conducted by two clinical nurses with master’s degrees in nursing. In case of disagreements, consultations were conducted with a third researcher to reach a consensus. The database search was restricted to English and Chinese.

Eligibility criteria

Literature Inclusion Criteria​: ​(1) Population (P): Patients who have undergone THA/TKA, and healthcare providers.​ ​(2) Phenomenon of Interest (I): Facilitators and barriers to postoperative rehabilitation exercise adherence in patients with THA/TKA.​ ​(3) Context (CO): Settings including hospitals, communities, and other relevant environments. ​(4) Study Type (S): Qualitative studies or the qualitative research component of mixed-methods studies.​Literature Exclusion Criteria: ​(1) studies that do not address the facilitators or barriers related to rehabilitation exercise in THA/TKA patients.​ ​(2) Studies not published in English or Chinese.​ ​(3) Duplicate publications.​ ​(4) Studies for which the full text is unavailable.​ ​(5) Mixed-methods studies where qualitative data cannot be separated or extracted independently.​ ​(6) Studies rated as “Grade C” in quality assessment.

Selection process

The search process was documented using EndNote, and duplicate articles were identified and removed through this software. The literature screening of this study was independently completed by two researchers with master’s degrees and qualifications in qualitative research, in strict accordance with the inclusion and exclusion criteria. In case of discrepancies during the screening process, the researchers first attempted to reach a consensus through cross-discussion; if the discrepancies could not be resolved, a third researcher was invited to join the consultation to ensure the objectivity of the screening results. A PRISMA flow diagram was used to illustrate the number of articles identified, included, and excluded, as well as to outline the study screening and selection process.

Quality appraisal

Two researchers trained in qualitative research methodology independently conducted quality assessment of the included literature using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research [9]. In cases where consensus could not be reached, a third researcher made the final determination. The assessment covered 10 items, and each item was rated as “Yes”, “No”, “Unclear”, or “Not Applicable”. Based on the official JBI guidelines and practical experience of relevant similar qualitative synthesis studies [10, 11], studies with 10 “Yes” responses are rated Grade A (low risk of bias and high study quality); those with 6–9 “Yes” responses are rated Grade B (moderate risk of bias and moderate study quality); and those with 3–5 “Yes” responses are rated Grade C (high risk of bias, with flaws in study design and low overall quality).

Data extraction

Data extraction was conducted independently by two researchers. The extracted information included the following items: authors of the literature, publication year, country of origin, research topic, data collection methods, data analysis methods, study population, phenomenon of interest, and main research findings. All extracted content was documented in a data extraction form. To ensure the rigor and accuracy of data extraction, the two researchers conducted a cross-check after the initial extraction to guarantee the consistency of the extracted information; for any inconsistent data identified during the cross-check, a third researcher was invited to join the discussion to reach a consensus.

Data analysis and synthesis

The thematic synthesis method developed by Thomas and Harden was employed to synthesize the qualitative research findings [12]. The entire research process was completed with the assistance of NVivo 20 software, which facilitated the classified management and independent coding of research data, enabling researchers to extract and mark key information accurately. Meanwhile, relying on its functions of code comparison and integration, the software provided technical support for the induction of descriptive themes and the construction of final themes. This synthesis process was carried out in three phases: (1) Two researchers first independently coded studies from patients and healthcare providers separately into Nvivo 20 to distinguish their different perceptions of the factors influencing rehabilitation exercise adherence; (2) Similarities and differences among the codes (including those between patient and healthcare provider perspectives) were identified through comparative analysis, and descriptive themes were further formulated based on these shared or distinct characteristics; (3) The two researchers generated descriptive themes and analytical themes by interpreting and integrating the coded results. Throughout each phase, the two researchers conducted data analysis and synthesis independently. In cases where discrepancies arose regarding coding, theme formulation, or theme integration, a third researcher was invited to participate in discussions to facilitate consensus-building, ensuring the objectivity and reliability of the synthesis results.

Reflexivity statement

The members of the research team have a professional background in nursing and extensive clinical experience in orthopedics. This background helps to identify the correlation between patients’ subjective experiences and clinical scenarios in the original studies, and to interpret the search results from a professional clinical perspective. However, it may also give rise to potential biases. For instance, subjective factors such as the researchers’ professional backgrounds, cultural backgrounds and value orientations will inevitably affect the objectivity of data processing and result interpretation.

Results

Results of the literature search

A systematic, transparent, and comprehensive approach for identifying and analyzing relevant literature was ensured in accordance with the PRISMA [13]. Figure 1 illustrates the screening process for the identified studies. A total of 686 articles were retrieved from 9 databases, among which 235 duplicate articles were excluded. After two researchers reviewed the titles and abstracts of the remaining 451 articles, 395 articles were excluded. The two researchers then independently read the full texts of the remaining 56 articles for further screening, in strict accordance with the pre-defined inclusion and exclusion criteria. Finally, a total of 19 studies were included in this review.

Fig. 1.

Fig. 1

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Literature screening flow chart

Quality appraisal of the studies

The detailed quality evaluation criteria for the 19 included studies are presented in Supplementary Material 2. Among these studies, 3 were rated as Grade A, and 16 were rated as Grade B. Ultimately, all 19 studies were included in the meta-synthesis.

Characteristics of the included studies

The 19 included studies were published between 2015 and 2025, and the studies were conducted across 7 different countries. Regarding data collection methods: 17 studies used semi-structured interviews, 1 study adopted focus groups, and 1 study employed both focus group interviews and semi-structured interviews. The participants of the studies were from a wide range of countries.​For data analysis methods: 7 studies used thematic analysis, 5 studies applied Colaizzi’s 7-step analysis method, 3 studies utilized content analysis, 2 studies adopted constant comparative analysis, 1 study used inductive and iterative data analysis, and 1 study employed procedural grounded theory.​The detailed general characteristics of the included studies are presented in Table 1. The specific themes and sub-themes are provided in Supplementary Material 3.

Table 1.

General characteristics of included studies

Author (year) Country Data Collection Methods Data Analysis Methods Population (number of participants) Phenomena of Interest
Liu et al. [14] (2024) China Semistructured interviews Colaizzi’s analysis 16 patients with TKA and 9 patients with TKA Influencing factors of in-hospital rehabilitation exercise behavior in patients after THA or TKA
Fan et al. [15] (2024) China Semistructured interviews Colaizzi’s analysis 12 patients with THA Influencing factors of early mobility in elderly patients with kinesiophobia after THA
Bakaa et al. [16] (2022) Canada Semistructured interviews Thematic analysis 7 patients with TKA Barriers and facilitators to exercise adherence in patients after TKA
Pellegrini et al. [17] (2018) United States Semistructured interviews Constant comparative analysis 20 patients with TKA Barriers and facilitators to healthy diet and physical activity in patients before and after TKA
Hawke et al. [18] (2022) Australia Semistructured interviews Inductive and iterative process of data analysis 22 patients with TKA Patients’ perceptions of physical activity after total knee arthroplasty TKA
Stenquist et al. [19] (2015) Dominican republic Semistructured interviews Content analysis 18 patients with TKA Physical activity and experiences of patients after TKA
Arant et al. [20] (2021) United States Semistructured interviews Thematic analysis 27 patients with TKA Patients’ perceptions of physical activity after TKA
Xie et al. [21] (2025) China Semistructured interviews Content analysis 11 nurses Influencing factors of implementing functional exercises in TKA patients with kinesiophobia
Zhang et al. [22] (2025) China Semistructured interviews Content analysis 24 patients with TKA Rehabilitation experiences of patients after TKA
Cai et al. [23] (2019) China Semistructured interviews Thematic analysis 14 patients with TKA Early Postoperative Functional Exercise Experience in TKA Patients with Kinesiophobia
Webber et al. [24] (2020) Canada Focus Group Interview Thematic analysis 8 patients with KOA and 14 patients with TKA Perspectives of patients with osteoarthritis and TKA on physical activity and sedentary behavior
Dan et al. [25] (2020) China Semistructured interviews Grounded theory analysis 12 patients with TKA Evolution of rehabilitation behavior in patients after TKA
Hoffman et al. [26] (2019) United States Semistructured interviews Constant comparative analysis 20 patients with TKA Perceived social and environmental barriers and facilitators to healthy diet and activity in patients before and after TKA
Chen et al. [27] (2024) China Semistructured interviews Colaizzi’s analysis 13 patients with THA Elderly patients’ experience of in-hospital rehabilitation training after THA
Zhu et al. [28] (2024) China Semistructured interviews Colaizzi’s analysis 12 patients with THA Early exercise rehabilitation experiences and needs of elderly patients after THA
Anne et al. [29] (2023) Denmark Semistructured interviews Thematic analysis 22 patients with THA Patients’ perspectives on home-based rehabilitation exercises and general physical activity after THA
Huang et al. [30] (2025) China Semistructured interviews Colaizzi’s analysis 8 patients with THA Early exercise rehabilitation experiences of elderly patients after THA
Madsen et al. [31] (2025) Denmark Focus Group Interview / Semistructured interviews Thematic analysis 6 physical therapists and 18 patients with THA Perspectives of patients and physical therapists on early physical rehabilitation exercises after THA
Louise et al. [32] (2018) United Kingdom Semistructured interviews Thematic analysis 11 patients with TKA and 17 patients with THA Patients’ perspectives on surgery and early recovery after THA or TKA
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Thematic synthesis

This study synthesized 78 research findings into 2 overarching themes and 10 sub-themes. The detailed Thematic Development Table is provided in Supplementary Material 4. The conceptual framework is provided in Supplementary Material 5.

Facilitators to rehabilitation exercise adherence in patients After THA/TKA

Self-motivation and rehabilitation goals

Seven studies [14, 16, 17, 20, 22, 27, 29] indicated that patients with strong self-motivation and clear rehabilitation goals were more likely to actively engage in rehabilitation exercises, thereby demonstrating higher adherence. This motivation is enhanced through two pathways: ① Perceiving physical improvements brought about by exercise, such as increased muscle strength, thereby establishing rehabilitation confidence [27]. ② Setting and achieving goals, and persisting in rehabilitation functional exercises even when rehabilitation progress fluctuates [16]. Patients’ expectations for functional recovery and return to normal life, such as pain-free activities and resumption of sports, are the intrinsic motivation for them to persist in rehabilitation [29].

Effective rehabilitation strategies

Five studies [15, 16, 18, 26, 27] emphasized that scientific and adaptive rehabilitation strategies are key elements in improving patients’ exercise enthusiasm, and can form a synergistic effect with patients’ self-motivation. From the perspective of patients’ practical experience, the combination of visualized guidance tools and clear exercise goals can effectively strengthen their exercise motivation. For instance, the activity monitoring function of wearable devices enables the rehabilitation effects to be directly perceived, thereby prompting patients to actively engage in exercise [26]; some patients also use customized rehabilitation materials to assist with training, such as the printed knee exercise manuals provided in rehabilitation programs [18] In addition, continuous care covering the entire rehabilitation cycle, especially professional guidance during the transition phase from in-hospital treatment to home-based rehabilitation, also plays an important role in maintaining patients’ exercise adherence [15].

Establishment of doctor-patient trust

Two studies [20, 31]indicated that building a trusting doctor-patient relationship contributes to improving patients’ adherence to rehabilitation exercises. When patients trust healthcare providers, they are more likely to eliminate concerns about rehabilitation and proactively follow professional guidance. This supportive role of trust is particularly prominent in the early postoperative stage, when patients worry about “prosthesis safety” and “rationality of exercise”.Oral reassurances and assessments from healthcare providers, based on their professional identity, can effectively alleviate such anxiety and strengthen patients’ trust in rehabilitation [31].The transmission of confidence in rehabilitation outcomes from doctors can further enhance patients’ trust and adherence [20].

Multidimensional support network

Seven studies [14–16, 26, 27, 30, 32] confirmed that the support network composed of family members, friends, and healthcare providers can form an external synergistic system with patients’ self-motivation, thereby improving their adherence to rehabilitation exercises. Among them, the daily supervision and emotional companionship from family members serve as an important support for patients to persist in exercise [14], while their daily care can also effectively reduce the burden of exercise on patients [16]; encouragement from friends can inject emotional motivation into patients [28]; and positive feedback from healthcare providers helps strengthen patients’ exercise persistence behaviors [14].

Barriers to rehabilitation exercise adherence in patients after THA/TKA

Physical symptoms and functional limitations

Findings from 16 studies [14–20, 22, 23, 25, 27–32] indicated that physical symptoms such as pain, fatigue, and functional limitations during the early postoperative period are the primary barriers to patients’ engagement in rehabilitation exercises. Among these symptoms, leg fatigue directly impairs the initiation and completion of exercises, making it difficult for patients to even perform basic rehabilitation movements [15], while also reducing the frequency of exercise [16]; residual pain continues to interfere with exercise outcomes even after painkillers are administered [15]; and the combined effects of pain and medication side effects create a “double barrier”, which further erodes patients’ motivation for exercise [18].

Kinesiophobia

Four studies [23, 27, 28, 30] indicated that kinesiophobia is a common problem among postoperative patients. Its essence is a fear-driven behavioral avoidance tendency, which directly reduces patients’ adherence to rehabilitation exercises. Among its manifestations, fear of falling is one of the primary forms of kinesiophobia [27]; while the strong avoidance mentality toward pain can further exacerbate kinesiophobia, and even lead patients to develop a conditioned avoidance response to rehabilitation exercises [23].

Cognitive biases

Seven studies [15, 23, 25, 27, 28, 30, 31] indicated that some patients who have undergone joint replacement surgery exhibit significant cognitive biases toward the rehabilitation process. Such biases refer to patients’ erroneous judgments about rehabilitation-related matters, specifically including: misjudgment of exercise timing, such as the belief that “early movement impairs wound healing” under the influence of the traditional concept that “injuries to muscles and bones require a hundred days to heal“ [28]; excessive worries about prosthesis safety, leading to the deliberate avoidance of strength training for fear of prosthesis loosening [23]; and the exacerbating effect of comorbidities on such biases, for example, concerns over wound healing in diabetic patients will further aggravate cognitive biases [27].Unlike kinesiophobia, which focuses on behavioral avoidance, cognitive biases are essentially erroneous perceptions at the cognitive level.

Lack of rehabilitation-related knowledge

Eight studies [15, 18, 19, 22, 23, 27, 30, 32] indicated that patients’ lack of knowledge related to rehabilitation exercises is a key factor affecting their rehabilitation adherence. Such a deficiency is specifically manifested in patients’ insufficient understanding of core aspects including exercise methods, timing, and precautions. Although some patients are aware of the importance of rehabilitation exercises, they often do not know how to carry out such exercises due to the lack of professional guidance [28]; alternatively, because they fail to master the correct methods, they can only perform simple basic movements and dare not rashly attempt other rehabilitation exercises [15]. Some patients even directly pointed out that the guidance provided by healthcare providers is obviously inadequate [19]. Memory decline and knowledge forgetting will further exacerbate this information deficiency, a problem that is particularly prominent among elderly patients. For them, remembering the requirements of complex rehabilitation guidance is an extremely challenging task [23].This factor is an objective practical barrier, which is distinct from subjective psychological and cognitive factors.

Psychological stress and negative emotions

Nine studies [14, 17, 19, 22, 23, 25, 27, 28, 30] indicated that psychological stress and negative emotions significantly impair patients’ enthusiasm for rehabilitation exercises. The emergence of such emotions is not only rooted in the temporary loss of physical function after surgery, but also closely associated with patients’ concerns about surgical outcomes and their resistance to the cumbersome treatment process, ultimately leading patients to avoid exercises and lose their motivation for rehabilitation. Among these factors, feelings of frustration can further evolve into a negative attitude toward everything, hindering the smooth implementation of postoperative rehabilitation activities [30]; frequent postoperative treatments and examinations can also exacerbate patients’ irritability [23]; in addition, patients’ unrealistic expectations for the rehabilitation process can trigger intense frustration when goals are not achieved, thus prompting them to abandon rehabilitation exercises [14].

Social environmental constraints

Four studies [14, 15, 30, 31] proposed that spatial constraints and a lack of rehabilitation equipment in the external environment are objective factors affecting patients’ adherence to rehabilitation exercises. When conducting rehabilitation exercises, patients often struggle to complete the scheduled training content due to various environmental issues, which ultimately leads to a decline in their exercise enthusiasm. These issues specifically include: the narrow space of hospital wards, which patients believe is not conducive to the conduct of rehabilitation exercises [14]; the absence of dedicated rehabilitation venues in the department [30]; and a shortage of rehabilitation auxiliary equipment [15].

Discussion

The rehabilitation exercise adherence of patients after THA/TKA is influenced by multiple factors. Through a meta-synthesis of 19 qualitative studies, this research categorized the influencing factors of rehabilitation exercise adherence into two core themes: facilitating factors and hindering factors, and further extracted 10 sub-themes. This classification helps healthcare professionals gain a clearer understanding of the internal driving forces and external constraints behind patients’ rehabilitation exercise behaviors, providing qualitative evidence support for the formulation of clinical intervention plans. Studies have shown that good rehabilitation exercise adherence is crucial for promoting postoperative joint function recovery and achieving optimal surgical outcomes [1]. Although numerous previous studies have explored the experiences of THA/TKA patients with postoperative functional exercises, most have focused on describing single-dimensional experiences and failed to systematically identify the facilitating and hindering factors affecting adherence, making it difficult to provide direct and comprehensive references for clinical practice. Therefore, exploring and clarifying the key factors influencing adherence is of great significance for optimizing rehabilitation management.

This study found that self-motivation and patients’ hope for functional reconstruction and return to normal life are internal factors enhancing rehabilitation exercise adherence. Ghahramanian et al. [33]conducted an empowerment intervention study based on self-efficacy in TKA patients. The results showed that patients in the intervention group had higher pain self-efficacy and significantly reduced pain intensity compared with the control group. Essentially, this was because patients gradually established the subjective perception of “I can control the rehabilitation process” during the intervention. Another study pointed out that patients with higher self-efficacy tend to have better mental states and can often form positive meaning interpretations of discomfort during rehabilitation, rather than perceiving it as a threat to be avoided. This cognitive difference reduces the incidence of kinesiophobia [34]. During the rehabilitation process, implementing targeted empowerment interventions to help patients establish awareness of autonomous rehabilitation is a key link in improving rehabilitation outcomes [35]. Enhancing patients’ confidence in their own abilities can thereby increase their initiative to engage in healthy behaviors [36]. Strong beliefs can also help patients resist various pressures during rehabilitation, persist in completing exercise plans, and thus improve adherence. Secondly, scientific and effective rehabilitation strategies are critical for improving postoperative rehabilitation outcomes. Studies have shown that comprehensive and scientific rehabilitation programs can accelerate postoperative joint function recovery, alleviate patients’ kinesiophobia, and thereby indirectly improve exercise adherence [37].Whole-cycle care can eliminate patients’ concerns about post-discharge rehabilitation and provide continuous support for maintaining adherence. Graber et al. [38] more intuitively confirmed the importance of personalized rehabilitation through interviews with TKA patients; some patients felt frustrated due to the lack of personalization in rehabilitation treatment, and this negative experience directly weakened their exercise motivation. In addition, a trusting doctor-patient relationship is an indispensable facilitating factor in the rehabilitation process of joint replacement patients. Postoperatively, THA and TKA patients often experience psychological burdens due to concerns about prosthesis safety and fear of the long-term rehabilitation process [39]. The establishment of a trusting doctor-patient relationship can alleviate patients’ psychological pressure, reduce worries about rehabilitation behaviors [40] and thereby encourage them to actively participate in rehabilitation exercises.

Finally, a multi-dimensional support network is an important external factor promoting patients’ rehabilitation exercise adherence. A meta-analysis confirmed that social support is a key prognostic factor for patient-reported outcomes 3 months or more after the first joint replacement, and can have a positive impact on rehabilitation outcomes [41]. Through interviews with THA patients, Mew et al. [42] further found that family support directly determines patients’ emotional status and mental health during rehabilitation. Patients with adequate family support are better able to face rehabilitation challenges positively, while those lacking family support often fall into loneliness and helplessness, and thus abandon exercise. This is consistent with the results of a qualitative study by Limbäck et al. [43] on motivation for maintaining exercise in arthritis patients: during rehabilitation, reminders and supervision as well as emotional companionship from family members and healthcare professionals can make patients feel that “they are not facing rehabilitation challenges alone”, thereby enhancing rehabilitation motivation and strengthening exercise adherence.

Rehabilitation exercise is a long and challenging process [44]. Through qualitative meta-synthesis, this study found that physical symptoms and physical function limitations are the most common objective factors hindering postoperative patients from persisting in exercise. THA or TKA patients often experience moderate to severe pain after surgery [45, 46] Patients included in the study generally reported that discomfort caused by pain made them give up exercise. Data show that 6% to 30% of joint replacement patients experience persistent pain after surgery [43], which directly leads to a decrease in rehabilitation exercise adherence. In addition, joint replacement surgery is relatively traumatic, and elderly patients are prone to fatigue, weakness, and other manifestations after surgery [47], which will further reduce their ability and willingness to participate in exercise. It should be noted that there is an interaction between pain and kinesiophobia. Pain not only prompts patients to reduce activities to avoid discomfort, leading to decreased lower limb muscle strength, but also induces kinesiophobia. In turn, kinesiophobia makes patients resistant to exercise, further reducing adherence, increasing the risk of complications such as lower extremity thrombosis and muscle atrophy, and adversely affecting joint function recovery [48]. Therefore, healthcare professionals should attach importance to postoperative pain management, rationally use analgesic drugs, conduct dynamic pain assessment, and formulate individualized analgesic plans to alleviate patients’ physical discomfort.

In addition to physical function limitations, lack of knowledge related to rehabilitation functional exercises and cognitive biases are also hindering factors reducing exercise adherence in hip and knee replacement patients. Studies have shown that problems such as insufficient rehabilitation knowledge reserve and vague understanding of the benefits of exercise are common among patients [5, 49]. When patients hold negative cognitions such as “exercise will aggravate pain” and “it takes a hundred days to recover from injury”, their adherence to rehabilitation will be directly reduced. In contrast, patients who have received adequate rehabilitation guidance have significantly higher postoperative exercise adherence. They know how to carry out functional exercises, so they are more willing to actively follow the rehabilitation plan [50]. Imrek et al. [51]confirmed that implementing preoperative education for TKA patients helps reduce their fear during the first postoperative activity, and adequate information support is one of the key factors in reducing postoperative kinesiophobia. In addition, preoperative education can also help patients establish reasonable rehabilitation expectations [52]. Through interviews with patients after hip and knee replacement, Keulen et al. [53]found that there is a gap in patient education in current clinical practice, which may lead to patients’ fear of surgery and anxiety about rehabilitation. Therefore, healthcare professionals need to meet patients’ rehabilitation education needs and provide systematic and comprehensive guidance to help patients form an objective understanding of postoperative pain and overall health status during rehabilitation, and avoid anxiety caused by cognitive biases [54].

Psychological factors are also important hindering factors affecting rehabilitation exercise adherence, and have an interaction with physical symptoms and cognitive biases. Li et al. [55] found that THA/TKA patients often experience negative emotions such as anxiety and depression after surgery, and the severity of anxiety and depression is positively correlated with pain perception. This conclusion is consistent with the research results of Nickinson et al. [56]. Through interviews with TKA patients, Zacher et al. [57] found that they have unrealistic expectations for postoperative joint function recovery. A qualitative study by Graber et al. [38] further confirmed that when these excessive expectations cannot be achieved, patients will experience strong frustration and loss, thereby weakening their exercise adherence. Moreover, a negative mindset is an important risk factor for the occurrence of kinesiophobia [58]. Therefore, healthcare professionals should closely monitor patients’ postoperative psychological status, and help them overcome psychological barriers through individualized psychological interventions and systematic rehabilitation education, promoting the transformation from passive rehabilitation to active participation, and ultimately improving rehabilitation exercise adherence.

Through qualitative meta-synthesis, this study found that physical symptoms, cognitive status, kinesiophobia, and social support together constitute a dynamically intertwined interaction network, which synergistically affects patients’ rehabilitation exercise adherence. Pain and fatigue at the physical level directly trigger patients’ fear of rehabilitation movements, prompting them to adopt exercise avoidance behaviors. In turn, such avoidance behaviors will consolidate patients’ incorrect cognitions, equating “mild discomfort associated with exercise” with “exercise will aggravate injury”. The social support network plays a key regulatory role in this process. Assistance and emotional companionship from family members and friends can alleviate patients’ fear and reduce their psychological burden; professional explanations and positive feedback from healthcare professionals can correct patients’ incorrect cognitions, strengthen their internal rehabilitation motivation and sense of control over the rehabilitation process, and ultimately improve rehabilitation exercise adherence.

Limitations

This study has certain limitations. First, there is homogeneity in the demographic characteristics of the study participants in the included literature, and the influencing factors of their rehabilitation adherence may differ from those of elderly patients or patients with multiple comorbidities, making it difficult to directly generalize the conclusions to the entire population. Second, only studies published in English and Chinese were included, while gray literature was excluded. Moreover, most of the included studies are from cultural contexts of English and Chinese-speaking countries, making it difficult to reflect the differences in the influencing factors of rehabilitation adherence across different cultural backgrounds and limiting the comprehensiveness of the results. Third, among the included studies, only 3 were rated as “A” in methodological quality, and most did not mention the impact of researchers’ values and cultural backgrounds. The overall quality is relatively low, which may increase the risk of bias. Fourth, there are differences in the design, data collection and result presentation of the included studies, which are prone to heterogeneity in integrated analysis, possibly leading to misinterpretation of results and affecting the reliability of conclusions. Finally, during the integration process, subjective factors such as researchers’ professional backgrounds and value orientations will inevitably affect data processing and result interpretation, which are difficult to completely eliminate and may increase the uncertainty of conclusions.

Conclusion​

This study identified the facilitators and barriers to rehabilitation exercise adherence in patients following THA/TKA through qualitative meta-synthesis, integrating qualitative research evidence from both patient and clinical perspectives. Clinically, healthcare providers can refer to the findings of this study to develop individualized intervention programs; rehabilitation exercise adherence can be improved by stimulating intrinsic motivation, strengthening doctor-patient trust, establishing a multidimensional support network, and addressing relevant barriers. Future research may focus on populations at different stages such as during hospitalization and after discharge home, explore the heterogeneity of influencing factors, and conduct longitudinal validation of intervention programs, so as to provide more solid evidence-based support for postoperative rehabilitation exercises.

Supplementary Information

Supplementary Material 1. (267.8KB, docx)
Supplementary Material 2. (16.4KB, docx)
Supplementary Material 3. (19.8KB, docx)
Supplementary Material 4. (16.6KB, docx)
Supplementary Material 5. (21KB, docx)
Supplementary Material 6. (31.6KB, docx)
Supplementary Material 7. (154.8KB, docx)

Acknowledgements

Not applicable.

Authors’ contributions

All authors contributed to the manuscript. NC and XY wrote the main manuscript text; YY was responsible for literature screening, data extraction, and table creation; YC participated in writing, supervised the progress of the manuscript, and reviewed the manuscript.

Funding

No funding was received for this study.

Data availability

Data are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  • 1.Mooiweer Y, Stevens M, van den Akker-Scheek I. Being active with a total hip or knee prosthesis: a systematic review into physical activity and sports recommendations and interventions to improve physical activity behavior. Eur Rev Aging Phys Act. 2022;19(1):7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Wu JQ, Mao LB, Wu J. Efficacy of exercise for improving functional outcomes for patients undergoing total hip arthroplasty: A meta-analysis. Med (Baltim). 2019;98(10):e14591. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.van Wietmarschen HA, Busch M, Jong MC. Guided and motor imagery for pain management and functional recovery after arthroplasty of the hip or knee: A pragmatic prospective mixed-methods study. Integr Med Res. 2026;15(1):101230. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Zhang W, Ji H, Wu Y, Xu Z, Li J, Sun Q, Wang C, Zhao F. Exploring patients’ experiences of self-management in rehabilitation following total knee arthroplasty: A qualitative study. J Health Psychol. 2025;30(14):4480–93. [DOI] [PubMed] [Google Scholar]
  • 5.Specht K, Agerskov H, Kjaersgaard-Andersen P, Jester R, Pedersen BD. Patients’ experiences during the first 12 weeks after discharge in fast-track hip and knee arthroplasty - a qualitative study. Int J Orthop Trauma Nurs. 2018;31:13–9. [DOI] [PubMed] [Google Scholar]
  • 6.Longo UG, Corradini A, Marchetti A, Di Sarno C, D’Angelo C, Arias C, De Marinis MG, de Sire A, Denaro V. I Am Afraid I Will Not Be Able to Walk, That Is What Worries Me-The Experience of Patients with Knee Osteoarthritis before Total Knee Arthroplasty: A Qualitative Study I Am Afraid I Will Not Be Able to Walk, That Is What Worries Me-The Experience of Patients with Knee Osteoarthritis before Total Knee Arthroplasty: A Qualitative Study. J Clin Med. 2024;13(10):2878. [DOI] [PMC free article] [PubMed]
  • 7.Öztürk R, Küçük Öztürk G. Life After Total Hip Replacement: A Qualitative Study on Patient Experiences. Orthop Nurs. 2022;41(3):213–20. [DOI] [PubMed] [Google Scholar]
  • 8.Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Majid U, Vanstone M. Appraising Qualitative Research for Evidence Syntheses: A Compendium of Quality Appraisal Tools. Qual Health Res. 2018;28(13):2115–31. [DOI] [PubMed] [Google Scholar]
  • 10.Wang Q, Li S, Gu J, Yang J, Chen J, Cheng H, Lin Z, Lei Y. Experiences and Perceptions of Food Avoidance in Patients With Inflammatory Bowel Disease: A Qualitative Meta-Synthesis. J Nurs Res. 2025;33(4):e407. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Boehm LM, Jones AC, Selim AA, Virdun C, Garrard CF, Walden RL, Wesley Ely E, Hosie A. Delirium-related distress in the ICU: A qualitative meta-synthesis of patient and family perspectives and experiences. Int J Nurs Stud. 2021;122:104030. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:45. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Liu H, Tang SQ, Wu H, Fu LQ, Wu J. A qualitative study on influencing factors of in-hospital rehabilitation exercise behavior in patients after total hip and knee arthroplasty. Chin Nurs Manag. 2024;24(4):530–4. [Google Scholar]
  • 15.Fan D, Zhou W, Li WQ, Ding XF, Li YP, Wu CL. A qualitative study on influencing factors of early activity in elderly patients with kinesiophobia after total hip arthroplasty. Contemp Nurse (Upper Issue). 2024;31(10):127–30. [Google Scholar]
  • 16.Bakaa N, Chen LH, Carlesso L, Richardson J, Shanthanna H, Macedo L. Understanding barriers and facilitators of exercise adherence after total-knee arthroplasty. Disabil Rehabil. 2022;44(21):6348–55. [DOI] [PubMed] [Google Scholar]
  • 17.Pellegrini CA, Ledford G, Chang RW, Cameron KA. Understanding barriers and facilitators to healthy eating and physical activity from patients either before and after knee arthroplasty. Disabil Rehabil. 2018;40(17):2004–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Hawke LJ, Taylor NF, Dowsey MM, Choong PFM, Shields N. In the Dark About Physical Activity - Exploring Patient Perceptions of Physical Activity After Elective Total Knee Joint Replacement: A Qualitative Study. Arthritis Care Res (Hoboken). 2022;74(6):965–74. [DOI] [PubMed] [Google Scholar]
  • 19.Stenquist DS, Elman SA, Davis AM, Bogart LM, Brownlee SA, Sanchez ES, Santiago A, Ghazinouri R, Katz JN. Physical activity and experience of total knee replacement in patients one to four years postsurgery in the dominican republic: a qualitative study. Arthritis Care Res (Hoboken). 2015;67(1):65–73. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Arant KR, Zimmerman ZE, Bensen GP, Losina E, Katz JN. Perceptions of Physical Activity and the Use of Activity Monitors to Increase Activity Levels in Patients Undergoing Total Knee Replacement. ACR Open Rheumatol. 2021;3(11):771–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Xie XQ, Jiang WL, Liang XY, Lu MF, Liao YH. A qualitative study on influencing factors of implementing functional exercises in TKA patients with kinesiophobia from nurses’ perspective. Contemp Nurse (Lower Issue). 2025;32(2):75–9. [Google Scholar]
  • 22.Zhang WZ, Ji H, Wu Y, Xu ZZ, Li J, Sun QX, Wang CL, Zhao FY. Exploring patients’ experiences of self-management in rehabilitation following total knee arthroplasty: A qualitative study. J Health Psychol. 2025;30(14):4480–93. [DOI] [PubMed]
  • 23.Cai LB, Liu YJ, Cui MR, Guo YR, Zheng SS, Wang YY. A qualitative study on early postoperative functional exercise experience of patients with kinesiophobia after total knee arthroplasty. Chin J Nurs. 2019;54(11):1663–8. [Google Scholar]
  • 24.Webber SC, Ripat JD, Pachu NS, Strachan SM. Exploring physical activity and sedentary behaviour: perspectives of individuals with osteoarthritis and knee arthroplasty. Disabil Rehabil. 2020;42(14):1971–8. [DOI] [PubMed] [Google Scholar]
  • 25.Shan YW, Chen WJ, Jin LJ, Chen R, Lin RJ. A qualitative study on evolution of rehabilitation behavior in patients after total knee arthroplasty. Chin J Nurs. 2020;55(10):1470–5. [Google Scholar]
  • 26.Hoffman SA, Ledford G, Cameron KA, Phillips SM, Pellegrini CA. A qualitative exploration of social and environmental factors affecting diet and activity in knee replacement patients. J Clin Nurs. 2019;28(7–8):1156–63. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Chen WX, Jin XH, Chen X, Zhang Y, Wang JZ, Liu F. A qualitative study on rehabilitation training experience of elderly patients after total hip arthroplasty during hospitalization. Mil Nurs. 2024;41(10):66–9. [Google Scholar]
  • 28.Zhu XX, Xu M, Zhao SJ, Wu H, Zhang H, Fu LQ, Jiang JX, Wu J. A qualitative study on early motor rehabilitation experience and needs of elderly patients after total hip arthroplasty. Chin J Mod Nurs. 2024;30(13):1745–9. [Google Scholar]
  • 29.Poulsen AG, Gravesen JD, Madsen MN, Mikkelsen LR, Bandholm T, Rossen CB. Patient perspectives on home-based rehabilitation exercise and general physical activity after total hip arthroplasty: A qualitative study (PHETHAS-2). F1000Res 2021;10:382. 10.12688/f1000research.51684.5 [DOI] [PMC free article] [PubMed]
  • 30.Huang XR, Yang HB, Song LN, Yang RS. A qualitative study on early motor rehabilitation experience of elderly patients after total hip arthroplasty. Fam Nurse. 2025;23(1):189–92. [Google Scholar]
  • 31.Madsen MN, Mikkelsen LR, Mark-Christensen T, Christiansen DH, Bandholm T, Tjørnhøj-Thomsen T. Patient and physical therapists’ views on physical rehabilitation exercise in the early phase after total hip arthroplasty: a qualitative interview study. Disabil Rehabil. 2025;47(19):5032–43. [DOI] [PubMed]
  • 32.Strickland LH, Kelly L, Hamilton TW, Murray DW, Pandit HG, Jenkinson C. Early recovery following lower limb arthroplasty: Qualitative interviews with patients undergoing elective hip and knee replacement surgery. Initial phase in the development of a patient-reported outcome measure. J Clin Nurs. 2018;27(13–14):2598–608. [DOI] [PubMed] [Google Scholar]
  • 33.Ghahramanian A, Mirmaroofi N, Asghari-Jafarabadi M, Behshid M, Tabrizi FJ, Onyeka T, Ganjpour J. The effect of an empowerment program on pain control and self-efficacy in patients undergoing total knee arthroplasty in Iran: a quasi-experimental study. BMC Musculoskelet Disord. 2025;26(1):875. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Hayward R, Stynes S. Self-efficacy as a prognostic factor and treatment moderator in chronic musculoskeletal pain patients attending pain management programmes: A systematic review. Musculoskelet Care. 2021;19(3):278–92. [DOI] [PubMed] [Google Scholar]
  • 35.Westby MD, Backman CL. Patient and health professional views on rehabilitation practices and outcomes following total hip and knee arthroplasty for osteoarthritis:a focus group study. BMC Health Serv Res. 2010;10:119. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Ghazi C, Nyland J, Whaley R, Rogers T, Wera J, Henzman C. Social cognitive or learning theory use to improve self-efficacy in musculoskeletal rehabilitation: A systematic review and meta-analysis. Physiother Theory Pract. 2018;34(7):495–504. [DOI] [PubMed] [Google Scholar]
  • 37.Zhang Y, Sun K, Li H. Application of a comprehensive clinical care pathway in patients undergoing total hip arthroplasty. Int J Orthop Trauma Nurs. 2025;59:101232. [DOI] [PubMed] [Google Scholar]
  • 38.Graber J, Lockhart S, Matlock DD, Stevens-Lapsley J, Kittelson AJ. This is not negotiable. You need to do this… A directed content analysis of decision making in rehabilitation after knee arthroplasty. J Eval Clin Pract. 2022;28(1):99–107. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Bergman L, Guenna Holmgren A, Nilsson U, Amirpour A, Conte H, Eckerblad J. The bumpy road to recovery: older adults’ experiences during the first year after hip replacement surgery - a longitudinal qualitative study. BMC Geriatr. 2025;25(1):483. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Najafi F, Shahsavari H, Mortazavi SMJ, Khodayari S, Jaafarpour M, Zare Z. Factors affecting decision-making for knee arthroplasty in patients with osteoarthritis. Int J Orthop Trauma Nurs. 2023;49:101016. [DOI] [PubMed] [Google Scholar]
  • 41.Wylde V, Kunutsor SK, Lenguerrand E, Jackson J, Blom AW, Beswick AD. Is social support associated with patient-reported outcomes after joint replacement? A systematic review and meta-analysis. Lancet Rheumatol. 2019;1(3):e174–86. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Mew LE, Heaslip V, Immins T, Wainwright TW. Young Hip: an exploration into young patients’ (aged < 50 years) expectations following primary total hip arthroplasty: a qualitative study. Bone Jt Open. 2025;6(7):807–15. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Limbäck G, Bilberg A. Experiences of supervised high-intensity interval training-a motivator for exercise maintenance among patients with rheumatoid arthritis: a qualitative interview study. BMJ Open. 2025;15(12):e106750. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Chen W, Qin X, Yang H, Tan Z, Liu P. Impact of cloud-based follow-up exercise prescription on knee function and quality of life in homebound patients post-total knee arthroplasty: a randomized controlled trial. J Orthop Surg Res. 2025;20(1):809. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Laigaard J, Aljuboori SM, Nikolajsen L, Mathiesen O, Lunn TH, Overgaard S. Chronic Postsurgical Pain after Primary Total Hip Arthroplasty for Osteoarthritis: A Nationwide Cross-Sectional Survey Study. J Arthroplasty. 2025. 10.1016/j.arth.2025.09.057. [DOI] [PubMed]
  • 46.Ghanbari F, Rejeh N, Bahrami T, Yahyazadeh H, Saatchi K. Comparative Effectiveness of Ear and Body Acupressure for Postoperative Pain in Elderly Women Following Knee Arthroplasty: A Randomized Trial. J Integr Complement Med. 2025;31(11):987–96. [DOI] [PubMed]
  • 47.Tao M, Yang J, Liu R, Zhang S, Han Y, Li C, Wei Q, Chen D, Fang J, Zhang H, et al. Efficacy of transcranial direct current stimulation for improving postoperative quality of recovery in elderly patients undergoing lower limb major arthroplasty: a randomized controlled substudy. Front Neurol. 2024;15:1327558. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Brown OS, Hu L, Demetriou C, Smith TO, Hing CB. The effects of kinesiophobia on outcome following total knee replacement: a systematic review. Arch Orthop Trauma Surg. 2020;140(12):2057–70. [DOI] [PubMed] [Google Scholar]
  • 49.You S, Li N, Guo M, Ji H. Are patients ready for discharge from the hospital after fast-track total knee arthroplasty?-A qualitative study. PLoS ONE. 2024;19(5):e0303935. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Timmers T, Janssen L, van der Weegen W, Das D, Marijnissen WJ, Hannink G, van der Zwaard BC, Plat A, Thomassen B, Swen JW, et al. The Effect of an App for Day-to-Day Postoperative Care Education on Patients With Total Knee Replacement: Randomized Controlled Trial. JMIR mHealth uHealth. 2019;7(10):e15323. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.İmrek AK, Yilmaz M. The effect of preoperative education on fear of first mobilization experienced after total knee arthroplasty in individuals. Int J Orthop Trauma Nurs. 2025;57:101189. [DOI] [PubMed] [Google Scholar]
  • 52.Causey-Upton R, Howell DM, Kitzman PH, Custer MG, Dressler EV. Orthopaedic Nurses’ Perceptions of Preoperative Education for Total Knee Replacement. Orthop Nurs. 2020;39(4):227–37. [DOI] [PubMed] [Google Scholar]
  • 53.Keulen MH, Boonen B, Leenders AM, Van Haaren EH, Schotanus MG, Bemelmans YF. Patients’ Perceptions and Experiences With Outpatient Hip and Knee Arthroplasty: A Qualitative Study. Cureus. 2025;17(2):e78781. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Buus A, Hejlsen OK, Dorisdatter Bjørnes C, Laugesen B. Experiences of pre- and postoperative information among patients undergoing knee arthroplasty: a systematic review and narrative synthesis. Disabil Rehabil. 2021;43(2):150–62. [DOI] [PubMed] [Google Scholar]
  • 55.Li H, Su Q, Qin L, Li Q, Li Y, Wang C, Zhu H, Li H. Knowledge attitude, and practice of patients with knee osteoarthritis towards perioperative functional exercise after total knee arthroplasty: a cross-sectional study. PeerJ. 2025;13:e19511. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Nickinson RS, Board TN, Kay PR. Post-operative anxiety and depression levels in orthopaedic surgery: a study of 56 patients undergoing hip or knee arthroplasty. J Eval Clin Pract. 2009;15(2):307–10. [DOI] [PubMed] [Google Scholar]
  • 57.Zacher S, Lauberger J, Thiel C, Lühnen J, Steckelberg A. Informed consent for total knee arthroplasty: exploration of patient`s information acquisition and decision-making processes-a qualitative study. BMC Health Serv Res. 2023;23(1):978. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Du X, Shao Y, Xue J, Kong J. Prevalence and influencing factors of kinesiophobia after total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2025;20(1):332. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

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Supplementary Materials

Supplementary Material 1. (267.8KB, docx)
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Supplementary Material 3. (19.8KB, docx)
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Supplementary Material 5. (21KB, docx)
Supplementary Material 6. (31.6KB, docx)
Supplementary Material 7. (154.8KB, docx)

Data Availability Statement

Data are available from the corresponding author on reasonable request.

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